The home health aide caring for a home bound hospice client calls to inform the nurse that the client has reported feeling constipated. Which task should the nurse instruct the home health aide to perform?
Listen for the presence of bowel sounds.
Teach the client about foods high in fiber.
Administer a prescribed dose of a laxative.
Assist the client in drinking warm prune juice.
The Correct Answer is D
Choice A Reason: Listening for the presence of bowel sounds is not a task that the home health aide can perform, as it requires a stethoscope and clinical judgment. This task is within the scope of practice of the nurse, who should assess the client's bowel function and abdominal status.
Choice B Reason: Teaching the client about foods high in fiber is not a task that the home health aide can perform, as it requires knowledge and education skills. This task is within the scope of practice of the nurse, who should provide dietary advice and counseling to the client and their family.
Choice C Reason: Administering a prescribed dose of a laxative is not a task that the home health aide can perform, as it requires medication administration skills and authority. This task is within the scope of practice of the nurse, who should check the medication order, verify the dosage and route, and document the administration.
Choice D Reason: Assisting the client to drink warm prune juice is a task that the home health aide can perform, as it requires basic care and assistance skills. This task is appropriate for the home health aide, who should encourage fluid intake and offer natural remedies for constipation, such as prune juice, which has laxative effects.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A Reason: Influenza is transmitted primarily through respiratory droplets. Droplet precautions require healthcare workers to wear a mask (surgical mask) when in close contact with a client. The UAP is already wearing gloves and a gown, which are appropriate for contact precautions but incomplete without a face mask for droplet protection.
Choice B Reason: A fitted respirator (e.g., N95) is unnecessary unless the client is suspected or confirmed to have an airborne transmissible disease such as tuberculosis. Influenza does not require airborne precautions.
Choice C Reason: Assigning the UAP to provide care for another client and assuming full care of the client is not necessary or feasible because it would increase the workload of the nurse and reduce the quality of care for both clients. The UAP can still assist with care for clients with influenza as long as they follow proper infection control measures.
Choice D Reason: Instructing the UAP to notify the nurse of any changes in the client's respiratory status is important but not a priority action because it does not address the issue of preventing transmission of influenza. The nurse should first ensure that the UAP wears appropriate personal protective equipment before entering the client's room.
Correct Answer is D
Explanation
Choice A Reason: This assignment does not require immediate follow-up action by the charge nurse because a practical nurse can transport a stable postoperative client to another unit and report any changes or concerns to the primary nurse.
Choice B Reason: This assignment does not require immediate follow-up action by the charge nurse because a practical nurse can monitor the blood pressure of a client with hypertension and administer antihypertensive medications as prescribed and delegated by the primary nurse.
Choice C Reason: This assignment does not require immediate follow-up action by the charge nurse because a graduate nurse can obtain a unit of packed red blood cells from the blood bank and verify the compatibility and identification with another registered nurse before transfusing it to the client.
Choice D Reason: This is the correct answer because checking a client for fecal impaction is beyond the scope of practice of unlicensed assistive personnel. It involves inserting a finger into the rectum and assessing for hard stool, which can cause injury or infection to the client. The charge nurse should intervene and assign this task to a registered nurse or a practical nurse.
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